Patricia W. Spitz

Toward an Epidemiology of Gastropathy Associated With Nonsteroidal Antiinflammatory Drug Use

The thesis of this paper is that gastropathy associated with nonsteroidal antiinflammatory drugs (NSAIDs) is the most frequent and, in aggregate, the most severe drug side effect in the United States. This work is based on a consecutive series of 2400 patients with rheumatoid arthritis followed prospectively for an average of 3.5 yr by ARAMIS, the American Rheumatism Association Medical Information System. We present a preliminary exploration of the magnitude of the problem, the population at risk, and the patients within that population who are at particularly high risk. Patients on NSAIDs had a hazard ratio for gastrointestinal (GI) hospitalization that was 6.45 times that of patients not on NSAIDs. Characteristically, high-risk patients for GI hospitalization and GI death are older, have had previous upper abdominal pain, have previously stopped NSAIDs for GI side effects, and have previously used antacids or H2-receptor antagonists for GI side effects. They also are frequently on corticosteroids. In contrast, patients attributing relatively minor symptoms to the drug tend to be younger and more frequently female. Our preliminary analysis is univariate and, as these variables are interdependent, firm conclusions regarding the relative importance of these risk factors will require reevaluating our data base as it is expanded using multivariate analysis. The syndrome of NSAID-associated gastropathy can be estimated to account for at least 2600 deaths and 20,000 hospitalizations each year in patients with rheumatoid arthritis alone.

The social function of young adults who had arthritis in childhood

One hundred twenty-one young adults 18 years of age or older who had been seen at this hospital with juvenile arthritis since 1955 were surveyed by a series of questionnaires to determine current social function and financial status. Chart reviews and patient questionnaires were used to determine modes of onset and the social circumstances of the family at the onset of the arthritis. The patients as a whole were functioning well: 45 were working full time, 25 were in school full time, 23 were in school and working, and 14 were married women at home. Females had a higher prevalence of persisting disability. Patients who had had a polyarticular onset had lower monthly salaries. No other disease or social variables at onset were statistically associated with any of the outcome variables measured. Fifty of the patients were compared to matched siblings and were found to have achieved comparable educations and salaries, and proportionate numbers of marriages and children.

The present and future of comprehensive outcome measures for rheumatic diseases.

SummaryIn recent years, outcome, or health status, measurement has received wide attention in rheumatology. These measures are based on the concept of maintaining or improving health as the goal of medical care, the World Health Organization (WHO) definition of health, and measurement of those factors that directly impact the patient rather than the traditional measures of disease process. Within this framework, outcomes important to the patient with rheumatic diseases have been identified. They have been conceptualized in general terms of physical, psychological and social functioning or specificallyy by dimensions of death, disability, discomfort, side effects and economic costs. Two widely used outcome measures, the health assessment questionnaire (HAQ) and the arthritis impact measurement scales (AIMS), are described. Outcomes are measured by patient self-reported questionnaires which have been rigorously tested to establish the measurement properties of reliability and validity. Results show that patient self-report is valid, outcomes are accurately measured, correlate with traditional endpoints, and are sensitive to change over time. These measures are particularly suited for use in follow-up studies because of their simplicity, ease of administration, and cost. Future directions include additional study to define clinically meaningful change, extension of validations to many of the rheumatic diseases, the design of special purpose questionnaires and the development of the cumulative outcome concept.